Alzheimer's Disease Drugs

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required but eligible patients will encounter a co-pay at the pharmacy.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
donepezil HCl ARICEPT TABLET Y 23 mg Require PA  
donepezil HCl DONEPEZIL HCL TABLET Y 23 mg Require PA  
galantamine HBr GALANTAMINE ER CAP24H PEL Y    
galantamine HBr RAZADYNE ER CAP24H PEL Y    
galantamine HBr GALANTAMINE HBR TABLET Y    
galantamine HBr RAZADYNE TABLET Y    
memantine HCl MEMANTINE HCL SOLUTION Y    
memantine HCl NAMENDA TAB DS PK Y    
memantine HCl MEMANTINE HCL TAB DS PK Y    
memantine HCl NAMENDA TABLET Y    
memantine HCl MEMANTINE HCL TABLET Y    
rivastigmine RIVASTIGMINE PATCH TD24 Y    
rivastigmine EXELON PATCH TD24 Y    
donepezil HCl DONEPEZIL HCL ODT TAB RAPDIS N    
galantamine HBr GALANTAMINE HYDROBROMIDE SOLUTION N    
memantine HCl NAMENDA XR CAP SPR 24 N    
memantine HCl NAMENDA XR CAP24 DSPK N    
memantine HCl/donepezil HCl NAMZARIC CAP SPR 24 N    
memantine HCl/donepezil HCl NAMZARIC CAP24 DSPK N    
rivastigmine tartrate RIVASTIGMINE CAPSULE N